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• To refresh your knowledge of various elements of communication
• To recognise the skills required to communicate effectively and provide person-centred care
• To learn about different communication models to support effective non-verbal and verbal communication
Communication is a process of sharing information and developing relationships through interaction. It is essential for nursing care, providing a basis for nurses to establish therapeutic relationships and trust with patients and their families. It is often assumed that nurses can intuitively communicate well; as a result, traditionally there has been a lack of formal training in this area. However, communication is a skill that can be developed and enhanced. This article explains the elements of communication and discusses the skills required by nurses to communicate effectively and provide compassionate, person-centred care. The author outlines two communication models to demonstrate how nurses can use these skills to deliver bad news and support people in distress.
Nursing Standard. doi: 10.7748/ns.2024.e12132
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Gregory J (2024) Understanding the communication skills that support nurses to provide person-centred care. Nursing Standard. doi: 10.7748/ns.2024.e12132
Published online: 02 January 2024
Communication takes place when information passes from one person or group to another person or group. It is the process of sharing information through messages and is crucial to achieving goals and developing relationships (Bramhall 2014, White 2021). Therefore, communication is an essential aspect of nursing and is the basis for nurses to foster interpersonal relationships with patients and their families. Effective communication can also enable patients to feel safe and confident in the treatment and care they are receiving (Grant and Goodman 2019). Nurses interact with a wide range of people in their practice, each of whom will respond individually to different situations and who may be experiencing emotions, such as fear, anger and embarrassment, in the healthcare context. Their emotions make each encounter unique, complex and challenging, requiring the nurse to adapt how they communicate based on the person’s needs (Price 2020).
An important aspect of a patient’s experience of healthcare is effective communication that demonstrates they are being treated as an individual and with dignity, humanity and compassion. The Nursing and Midwifery Council (NMC) (2018) standards of proficiency describe effective communication as ‘central to the provision of safe and compassionate person-centred care’.
This article discusses the main elements of communication and the skills that nurses require to communicate effectively. It also examines various models that may assist nurses when communicating with patients, families and colleagues. The article aims to encourage nurses to review and reflect on their communication skills to enhance their practice.
Effective communication can enhance patients’ emotional health, reduce anxiety and improve disease prevention and treatment and patient satisfaction (Bramhall 2014, Cannity et al 2021). Nurses’ communication skills are crucial in supporting patients to understand their health conditions, thus enabling them to participate actively in shared decision-making that is aligned with their personal goals and values (Bloomfield and Pegram 2015, Black et al 2019).
Suboptimal communication can have several consequences; for example, it may be a barrier to effective care and cause distress and misunderstandings, lower patient satisfaction, reduced adherence to treatment and adverse health outcomes (Cannity et al 2021). Many complaints received by the NHS relate to suboptimal communication and attitudes by healthcare staff. For example, a report on written complaints about the NHS found that communication was the most frequent issue and was the subject of around 17% of complaints in 2021-22 (NHS Digital 2022). Investigating complaints involves senior staff and uses valuable resources, therefore improving communication is not only important to meet patients’ expectations and values, but also to optimise the use of limited NHS resources.
• Effective communication can enhance patients’ emotional health, reduce anxiety, and improve disease prevention and treatment
• Nurses require self-awareness, active listening, compassion and empathy to communicate effectively
• Accessing formal training can develop and improve nurses’ communication skills and increase their job satisfaction
Person-centred care requires nurses to focus on the individual patient, establishing trust and a connection with them to support the development of a therapeutic relationship that assists the patient to express themselves (Bloomfield and Pegram 2015, Stonehouse 2021). Person-centred care enables the individual to be an active participant in their care, ensuring that their personal goals, needs, wishes and beliefs are taken into account when decisions are being made about their care and treatment (Bloomfield and Pegram 2015, Stonehouse 2021).
The NMC (2018) emphasises that nurses require a range of communication skills to ensure that patients, families and carers are ‘actively involved in and understand care decisions’. Therefore, nurses need highly developed interpersonal skills to establish therapeutic relationships and meet individual needs (Feo et al 2017).
Patients are unique individuals with their own preferences, values and beliefs, and relationships, which should be respected by nurses as part of providing person-centred care (Bloomfield and Pegram 2015). It is important to be aware of how an individual’s culture can influence their values and beliefs – including how the nurse’s culture may influence their own values and beliefs – but to also avoid stereotyping and making assumptions based on a person’s cultural group or background (Bloomfield and Pegram 2015, Tuohy 2019). To ensure they provide person-centred care, nurses should use their communication skills to gain an understanding of the unique person they are caring for, while considering the potential influence of cultural factors (Tuohy 2019).
Verbal communication is typically the first means considered to transfer a message. It is important that nurses use unambiguous language to ensure that their verbal communication is clear, understood by the recipient and does not give false hope in terms of prognosis and treatment outcomes (Glass 2010, Kermerer 2016). Although technical language, jargon and abbreviations are common in healthcare, where possible nurses should avoid using these when communicating with patients and families. Using plain English and breaking information into small ‘chunks’ can reduce some of the complexity of medical language used (Price 2020).
Nurses also need to consider whether English is the person’s first language and if they are likely to need additional time to consider the questions asked or further information before responding. If required, the services of an interpreter should be made available (Tuohy 2019). It is important to check that the individual has understood what has been said and that the nurse has heard and understood what the individual meant in their response. Paraphrasing and/or reflecting back the words used by the person can clarify understanding (Price 2020).
Nurses should keep in mind that although they might frequently encounter patients with certain healthcare conditions in their everyday practice, being diagnosed with one of these conditions can be a major event in a person’s life. Therefore, the nurse should consider the language they use during interactions; for example, using terms such as ‘it is only’ or ‘a simple’ may appear dismissive and may adversely affect the person concerned. Similarly, saying ‘don’t worry’ often closes a conversation and can make an individual feel that they have overreacted, preventing them from expressing any further concerns or fears (Grant and Goodman 2019).
Paraverbal communication, or paralanguage, includes the tone, volume, pitch, intonation and pace of speech (Thompson 2011) and can alter the meaning of what is said. Therefore, it is important that nurses are aware of various aspects of paraverbal communication when interacting with patients, families and colleagues.
In relation to pace of speech, in the author’s clinical experience, the nurse may want to speed up when speaking when there are time pressures, but doing so can make it challenging for the individual to hear what is being said. This can lead to the nurse having to repeat what they have said, thereby taking up more time. Conversely, speaking too slowly could be regarded as patronising or talking down to people, which has been observed when a patient is older or hard of hearing.
A person’s tone of voice, volume and pitch can also convey different meanings. For example, a soft tone of voice can demonstrate caring but also meekness, while a harsher tone can demonstrate urgency (White 2021). Shouting, which may occur when an individual cannot hear or understand what is said, can suggest anger. Increased pitch at the end of a sentence often indicates a question (White 2021). Intonation, which refers to how different words are emphasised in a sentence, can alter the meaning of what is said. For example, if a nurse asked: ‘How are you today?’ and emphasised the word ‘you’, this could indicate that they are interested in the person; however, if they emphasised the word ‘today’ this could suggest that they expect the person’s condition to have changed.
Non-verbal communication includes spatial awareness, body language, posture and facial expressions and is believed to comprise more than half of communication (Glass 2010). It can convey presence, attention and understanding (Jack 2022). However, suboptimal non-verbal communication can create a barrier to effective interactions with others and might discourage the other person from talking openly. Additionally, what is being communicated verbally needs to be congruent with non-verbal signals; for example, if the nurse has a worried expression this would be incongruent with them saying ‘everything is okay’ and could cause confusion.
The nurse should be aware of the distance between themselves and the person they are communicating with, known as spatial awareness (White 2021). If they are positioned too far away, they will appear distant, whereas if they are too close it will invade the patient’s personal space. People will have individual preferences as to how much space they would like, and their reaction will indicate an acceptable distance. Additionally, where possible, it is important for the nurse to be at the same level as the person they are talking to without a barrier such as a desk. Standing above someone can appear intimidating or as if they are talking down to them, so being seated lessens this possibility (Buckman 2005).
Body language, posture and facial expressions can influence how a message is received and interpreted. For example, folded arms and legs may suggest a defensive attitude, whereas open or uncrossed arms and legs indicate that the person is open and receptive to what the other person has to say (Stickley 2011). Leaning forward indicates interest, whereas leaning back might give the impression of lack of interest (White 2021). Furthermore, appearing awkward and tense fails to send a confident message, whereas being at ease and calm may promote a calm and relaxed atmosphere for a conversation. Facial expressions are also important to consider; for example, frowning may have a negative effect on the other person, whereas smiling appropriately can have a positive effect (Kermerer 2016, Grant and Goodman 2019). The patient’s facial expressions may indicate their response to what is said (Grant and Goodman 2019).
Maintaining appropriate eye contact can indicate that the nurse is interested and paying attention to what the person is saying (Buckman 2005). Eye contact should be intermittent to avoid appearing to stare. If the nurse avoids making eye contact this may indicate they are not listening, which does not encourage trust or disclosure. If a patient avoids eye contact, this can suggest strong emotions or a lack of trust (Kermerer 2016). However, it should be noted that in some cultures direct eye contact is considered confrontational (Tuohy 2019) and that certain people may find eye contact uncomfortable, such those who are autistic, in which case adjustments may need to be made.
It is important to remember that various aspects of non-verbal communication may be absent when communicating on the telephone or electronically. Therefore, it is essential to ensure that verbal or written words are conveyed clearly and carefully to reduce the risk of misunderstandings or distress.
Two models for effective non-verbal communication are the SOLER model (Egan 1975) and the SURETY model (Stickley 2011) (Box 1). Both models focus on body language, with the SURETY model building on and including aspects of the SOLER model (Egan 1975).
SOLER model (Egan 1975)
• Sit squarely
• Open posture
• Lean forward – lean towards the other person
• Eye contact – use eye contact as appropriate, without staring
• Relax – avoid appearing tense or fidgeting
SURETY model (Stickley 2011)
One aspect of the SOLER model omitted from the SURETY model is leaning forward to indicate interest, while the use of touch and nurses’ intuition to guide communication were added (Stickley 2011). Touch can convey empathy, but its use must be appropriate. For example, a gentle touch on the hand or shoulder may seem appropriate but should be guided by the individual’s reaction (Buckman 2005). The nurse may wish to hug a patient or family member if they appear upset or distressed, but should seek their permission to do so, otherwise it may be inappropriate and invade their personal space. Nurses also need to be aware of cultural differences, for example in some cultures touch may be unacceptable between people of different genders (Tuohy 2019).
Benner (1984) described intuition as ‘perceptual awareness’; that is, a ‘gut feeling’ or ‘hunch’. Intuition is considered part of an expert nurse’s judgement and is acquired over time through experience of many similar situations (Benner 1984). Therefore, for less experienced nurses, a simpler structure such as the SOLER model may be more useful in developing their communication skills before they acquire sufficient intuition through experience.
Nurses require a range of skills for communicating effectively, including self-awareness, active listening, compassion and empathy.
Self-awareness is a conscious, ongoing process of understanding oneself that entails self-discovery, observing and exploring how one’s behaviour affects others (Jack and Smith 2007, Jack 2022). Reflection can increase self-awareness and assist nurses in developing effective professional and therapeutic relationships by enabling them to recognise the effect of their behaviour on others (Jack 2022).
Self-awareness can enhance communication skills (Jack and Smith 2007); for example, it can assist nurses in becoming aware of their posture or facial expressions when interacting with others, thus enabling them to adapt these aspects to optimise communication. Furthermore, nurses’ awareness of how their personal values and beliefs, attitudes and assumptions about themselves and others may influence their behaviour can enable them to consider consciously how these affect the way they communicate with and respond to those around them (Tuohy 2019, Stonehouse 2021).
Active listening is a skill required by nurses (NMC 2018) and involves demonstrating interest in another person’s perceptions and experiences and focusing entirely on the person and what they are communicating verbally and non-verbally (Grant and Goodman 2019, Price 2020). Listening is highly valued by patients (Percy and Richardson 2018) and it is essential that they feel their experiences and perspectives are valued and recognised (Price 2020).
When actively listening to an individual, it is important that the nurse avoids being judgemental, interrupting or rehearsing a verbal response. Instead, the nurse should respond by using prompts such as head nodding and short words or cues, for example ‘I see’ or ‘yes’, that encourage the person to continue talking or to explain further (Grant and Goodman 2019). Nurses can reflect back what the person has said or use paraphrasing to demonstrate they are listening and to clarify the person’s meaning (Price 2020).
Silence is an important aspect of active listening. Many people find silence uncomfortable and might feel an urge to fill it. However, when used intentionally, silence can enable a patient to feel listened to and can give them time to acknowledge, process and reflect on any changes to their health (Kermerer 2016).
Bramhall (2014) described compassionate care as an interpersonal activity and complex connection that is ‘concerned with the way we relate to others when they are vulnerable’. Compassion is an essential aspect of nursing and is demonstrated by one’s attitudes and behaviours (Bloomfield and Pegram 2015). It is also linked to empathy, which was described by Rogers (1957) as a sense of the private world of another person as if it was your own, while being aware that one can never really experience how another person is feeling. Empathy is an essential aspect of nursing that supports compassionate communication and the development of therapeutic relationships (Wright 2021, Jack 2022).
It is important to recognise that each individual has had unique experiences that influence how they feel about situations, so it is not possible to know exactly how someone else feels. However, the nurse can appreciate or imagine how they may feel. An inability to understand how someone is feeling from their perspective may lead to substandard care (Grant and Goodman 2019). Nurses might wish to self-disclose and discuss their own experiences when attempting to empathise with a patient, but this should be avoided because it could breach professional boundaries (Feo et al 2017).
Various models have been developed to provide structures that can assist nurses and other healthcare professionals with communication. In this section the author examines two models: the SPIKES protocol (Baille et al 2000), which can be used when breaking bad news; and the SAGE & THYME model (Connolly et al 2010), which may be useful when recognising and responding to people who are distressed.
The responsibility for breaking bad news in the UK has increasingly become an aspect of the nurse’s role (Trueland 2020). Bad news has been defined as information that can change an individual’s view or expectations of their future (Buckman 2005). People’s perceptions of bad news can vary therefore the effects of such information are often unpredictable. Traditionally, breaking bad news has been regarded as the moment when patients and their families receive significant information about their diagnosis, prognosis and treatment options. It can also include delivering everyday information, such as delays in treatment and cancelled appointments. Breaking bad news is often stressful for the person delivering the information as well as the person receiving it (Dean and Willis 2016). However, Baille et al (2000) emphasised that patients want the truth and desire information to make decisions.
Compassionate communication skills are required to deliver bad news. If bad news is delivered effectively it can lead to acceptance and understanding; conversely, inappropriate delivery can cause distress and may have lasting adverse effects (Dean and Willis 2016). The skills required to deliver bad news include awareness of body language, active listening, empathy, and managing patients’ expectations and emotions (Baille et al 2000).
To deliver bad news effectively, nurses may wish to use the SPIKES protocol (Baille et al 2000) (Box 2), which is a stepwise process originally produced for oncologists. The protocol is now widely recommended for use in various healthcare settings (Seifart et al 2014), although Dean and Willis (2016) identified a lack of robust research evaluating its use.
The SAGE & THYME model (Box 3) can be used for noticing, listening to and responding to people who are distressed (Connolly et al 2010). Griffiths et al (2015) described the model as person-centred, since it is used to explore an individual’s concerns and involve them in identifying their own coping strategies, rather than giving premature advice that might close down the conversation.
• Setting – find somewhere private and quiet and sit down
• Ask – ask what the person is concerned about
• Gather – gather all of the person’s concerns; ‘Is there something else?’
• Empathy – respond sensitively, using empathic statements
• Talk – ask ‘Who do you have to talk to or help you?’
• Help – ask ‘How do they help?’
• You – ask ‘What would you like to happen?’
• Me – ask ‘Is there anything you would like me to do?’
• End – summarise and close the conversation; ‘Can we leave it there?’
Training in the use of the SAGE & THYME model has been implemented widely throughout the UK and several evaluations have demonstrated this training is highly valued by participants (Connolly et al 2010, 2014). District nurses (n=33) involved in focus groups reported that the structure of the model facilitated the opening and closing of conversations and increased their confidence, and they were highly motivated to use the model (Griffiths et al 2015).
The SPIKES protocol and the SAGE & THYME model can support nurses to be compassionate and person-centred by focusing on the individual. Both frameworks recognise the importance of involving patients and obtaining their perceptions and ideas before giving information and/or advice. Empathy and summarising the conversation are also among the main elements used in both frameworks, which are linked to active listening. However, following the structure of these frameworks too closely could lead to a mechanistic approach, so nurses should be aware that these are tools that should be adapted to meet the needs of individuals and the circumstances (Dean and Willis 2016).
It is often assumed that nurses can intuitively communicate well because communication is an essential aspect of person-centred care; however, this is incorrect – communication is a skill that can be refined and developed (Price 2020). Traditionally there has been a lack of formal communication skills education and training in healthcare; instead, communication was a skill learned by watching and listening to others (White 2021). However, it could be argued that without adequate knowledge it is not possible to observe and recognise effective practice.
While communication is now included in nurse education curricula, and communication skills are included in the NMC (2018) standards of proficiency, the number of complaints received about communication issues appear to suggest that there is a need for improvement (NHS Digital 2022). Communication skills training may improve patient satisfaction and relationships, increase job satisfaction and reduce levels of burnout in healthcare staff (Darban et al 2016). Bramhall (2014) and Black et al (2019) recommended training for all clinical staff to develop and enhance their communication skills. Nurses can also reflect on their communication skills in practice to increase their self-awareness and enhance patient experience (Price 2020).
Accessing communication skills training can enhance nurses’ performance and self-awareness, particularly if the training includes experiential learning, where nurses can practise different aspects of communication (Wilkinson et al 2008, Cannity et al 2021). Simulation-based training can enable nurses to practise communication skills in a safe environment, for example by acting out scenarios in groups of three, with one person playing a nurse, one person playing a patient and another person being an observer who provides guided feedback (Percy and Richardson 2018). Filming such interactions enables the nurse to observe themselves, thus increasing their self-awareness and identifying areas for development.
Effective communication is an essential skill for nurses and is fundamental to providing compassionate, person-centred care. In addition to developing their verbal communication skills, nurses need to understand how elements of non-verbal communication such as body language and facial expressions can influence how a message is delivered and received. Nurses also need to be able to demonstrate self-awareness, active listening and empathy to ensure patients feel heard and that their experiences and perspectives are valued. Nurses can use various models to assist them with communication, such as the SPIKES protocol and the SAGE & THYME model. Finally, evidence suggests that attending formal training can develop and enhance nurses’ communication skills.
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